Conscious sedation aims to provide analgesia, amnesia, and sedation while maintaining protective airway reflexes and spontaneous breathing. It requires patient selection, assessment, monitoring by experienced personnel, and availability of emergency equipment. Difficult airways may require additional airway management techniques and equipment for intubation. Proper preparation, including airway examination and fasting, helps ensure safe delivery of conscious sedation.
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Conscious Sedation Airway Management
1. Definition
conscious sedation is a clinical technique that
creates a decreased level of awareness for a patient yet
maintains protective airway reflexes and adequate
spontaneous ventilation.
2. THE GOAL
The goals of conscious sedation are to provide :
1-analgesia
2-amnesia
3-sedation
4-protect the airway and adequate spontaneous
ventilation
5-keep cardiovascular system within normal
range
3. Summary
Safe conscious sedation can provide by
following situation :
1.Fit patient selection
2.Adequate preoperative assessment
3.Adequate preparation
4.(Familiarity with Ready & Functioning
Equipment & Medications)
5.Functional monitoring
6.Adequate IV access
7.Experienced personnel (Doctor and Nurse)
8.Recovery room( staff -monitoring-discharge
criteria )
4. Contraindication
1. Non fasting patient
2. Physical class III –IV or greater
3. Lack of support staff, drugs, mon
itoring or equipment
4. Lack of experience/approved
on part of clinician
5. Patient not ready ,no consent
5. Conscious Sedation in the
hospital has policies and
guidelines approved by :
1-The Head of Anesthesia
2-The nurse manager
3-The appropriate department heads
6. Physicians who perform conscious
sedation are certified as appropriate in
BCLS, ACLS,PALS, NALS .
And have privileges granted to perform
conscious sedation
7. Nurses who assist with sedation/analgesia
are certified in BCLS, ACLS or PALS , NALS
according to the age of the patient.
8. Conscious sedation is performed
only in areas identified in policy and
the following equipment is available
to provide safe care
An oxygen source
Airways and Bag mask ventilation
Laryngoscopes (direct and video)
Several endotracheal tubes of different sizes
Suction ,tape
Oximetry AND Capnography
Stethoscopes
All equipment for DIFFICULT AIRWAY or INTUBAIONT…!?
Blood pressure and electrocardiography (ECG) monitors
Intravenous access with all anesthetic medication
Crash cart with defibrillator
9. The contents of a crash cart vary from hospital to hospital, but
typically contain the tools and drugs needed to treat a person in or
near cardiac arrest. These include :
Monitor/ defibrillators, suction , bag valve masks (BVMs) of different
sizes
Advanced cardiac life support (ACLS) drugs such
as epinephrine, atropine, amiodarone, lidocaine, sodium
bicarbonate, dopamine, and vasopressin
First line drugs for treatment of common problems such
as: adenosine, dextrose, diazepam or midazolam, epinephrine for IM
use, naloxone, nitroglycerin, and others
Drugs for rapid sequence intubation: succinylcholine , rocuronium or
another paralytic, and a sedative such as etomidate or
midazolam; endotracheal tubes and other intubating equipment
Drugs for peripheral and central venous access· Pediatric equipment
(common pediatric drugs, intubation equipment, etc.)
Other drugs and equipment as chosen by the facility
12. Pulse Oximetry and capnography
Pulse Oximetry : Measures of spo2
95% - 100% Normal
90% - 95% - Mild – Normal for COPD
< 90 % - low – Need Oxygen
Capnography : USED IN VERIFICATION OF
ETT PLACEMENT
17. The anatomy of the mouth and throat can
vary significantly from person to person.
Different sizes of the face mask (transparent)
18. The anatomy of the mouth and throat can
vary significantly from person to person.
Different sizes of the face mask (black rubber)
19. Grade I- Mask ventilated easily
Grade II- Mask ventilated with (oral
airway or nasal airway)
Grade III- Difficult to mask ventilate
even with airways
Grade IV- Unable to mask ventilate
Note: 8 min of hypoxia may be causes
irreversible brain damage
23. IN MRI
All equipments should be
MRI Compatible
EG.MRI Compatible Laryngoscope
Handle and blade
24. POSITIONING
When cervical spine pathology is suspected,
the head must be kept in a neutral position
during all airway manipulations.
BAG AND MASK VENTILATION
Bag and mask ventilation (BMV) is the first step
in airway management BUT In rapid sequence
inductions avoid BMV or positive pressure
ventilation to avoid stomach inflation and to
reduce incidence of aspiration
.
26. AIRWAY MANAGEMENT
Airway management associated with conscious sedation
consists of:
• Airway assessment
• Preparation and equipment check
• Patient position
• Preoxygenation
• Bag and mask ventilation (BMV) (if indicated)
• Intubation (if indicated)
• Confirmation of endotracheal tube placement
• Intra procedure management
• Extubation
27. Clinical Significance of Conscious Sedation
Airway assessment is a critical tool before
sedation ,anesthesia and intubation. conscious
sedation may be associated with depression of
airway reflexes and ventilation , so pre‐sedation
history and airway assessment are critical to the
delivery of safe sedation.
.
28. ASSESSMENT OF THE AIRWAY :
Pre Procedure: Consent
Explanation of the risks, benefits, and alternatives to sedation
must be provided to patient.
Airway assessment is the first step in successful
airway management.
Several anatomical and functional investigation
can be performed to estimate the difficulty of
(conscious sedation or endotracheal intubation ((IF
INDICATED)) )
However, it is important to note that successful
ventilation (with or without intubation) must be
achieved by ANESTHESIA DOCTOR …..
29. ASSESSMENT OF THE AIRWAY :
I . History : Medical, surgical or anaesthetic factors may be indicative of a
difficult airway (DA).
II . General, physical and regional examination
:
include the following:
look for masses inside nasal cavity
Mouth opening
iii. Teeth : Prominent upper incisors.
Palate : A high arched palate, narrow mouth
may present difficulty.
vi. Temporo-mandibular joint movement : It can be
restricted ankylosis , fibrosis, tumors…
30. vii. Measurement of submental space (hyomental/
thyromental length should be > 6 cm).
viii. Observation of patient’s neck : A short, thick neck is
often associated with difficult intubation..
ix. Presence of hoarse voice/stridor or previous
tracheostomy may suggest stenosis.
x. Any systemic or congenital disease requiring
special attention during airway management
(e.g. respiratory failure, significant coronary artery
disease, acromegaly,allergy …).
xi. General assessment of body habitus can give important
information.
xii. Infections of airway (e.g. epiglottitis, abscess, croup,
bronchitis, pneumonia).
NOTE : ASA classification 1‐3 are eligible for moderate/deep sedation
American Society of Anesthesiologists (ASA):
31.
32. Pre Procedure Fasting
1- infants are feed breast milk up to 4 h
2- formula or liquids and a “light” meal up to 6 h
3- Clear fluids 2–3 h before sedation
4- adult up to 6 h before sedation
NOTE
These recommendations are for healthy neonates,
infants, children and adult without risk factors for
decreased gastric emptying or aspiration
33. Thyromental distance: the distance between
The mentum and the superior thyroid notch.
A distance greater than 3 fingerbreadths is normal
Sterno-mental distance :
the distance from the suprasternal notch to the
mentum If less than 12 cm suspected difficult
airway and intubation .
Neck circumference: a neck circumference
of greater than 27 in is suggestive of difficult
airway and intubation.
37. Mallampati classification:
Difficult airway and intubation may be in class (III),( IV)
■ Class I:all are visible :tonsills,uvula,soft and
hard palates
■ Class II: the upper part of the
Tonsills and upper part of uvula
and soft and hard palates are visible .
■ Class III: only the soft and hard palates are
visible.
■ Class IV: only the hard palate is visible.
Test is performed with the patient in the sitting
position, head in a neutral position, the mouth wide
open and the tongue protruding to its maximum
45. Joint disease
Acromegaly
Thyroid or major
neck surgeries
Airway Tumors
Epiglottitis
Previous problems in
surgery
Diabetes
Pregnancy
Obesity
Condition associated with difficult airway
46. Morbid OBESITY
Morbid obesity and body mass index (BMI) of 26 or
greater my be suspected difficult airway or intubation .
NOTE: Not only may these patients prove to be
difficult intubation, but routine ventilation with bag and
mask also may be problematic.
Note: 8 min of hypoxia may be
causes irreversible brain damage
47. .
Difficult mask ventilation describes the situation in which it may
be difficult or impossible to oxygenate and ventilate a patient
It is not possible for the unassisted anesthesiologist to maintain
SPO2>90% using 100% O2 and positive pressure mask ventilation
in a patient whose SPO2 was > 90% before anesthetic intervention
using a bag mask technique by experienced and skilled doctor.
Difficult tracheal intubation describes a situation in which
it may be difficult or impossible to correctly place an
endotracheal tube by experienced and skilled doctor .
48. Signs and Symptoms of Airway
Obstruction:
Increased Respiratory Effort
Sternal Retractions
Inspiratory Stridor
Hypoxemia
Hypercarbia
Absence or Diminished Breath Sounds
49. Here we have some pictures for
patients with difficult airways ,in
these situations should not be do
conscious sedation without
attendance of high qualified
Anesthesia Doctor
63. COMBITUBE
The Combitube is usually inserted blindly through the mouth
The Combitube has two inflatable cuffs, a 100-mL
proximal cuff and a 15-mL distal cuff , both of which
should be fully inflated after placement